AccountId: 011433970860
ContactId: 74597149-2d63-4186-92de-8fe9f2db0517
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 687859 ms
Total Talk Time (AGENT): 301356 ms
Total Talk Time (CUSTOMER): 235944 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/11/74597149-2d63-4186-92de-8fe9f2db0517_20250211T18:33_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, I just received an explanation of benefits about, uh, some claims I sent in, and I need some help. I just talked to my providers, uh, billing department, and they said what they sent me was all they had.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I'm hearing from you guys that they need more you need more, so I, I need some verification here please.
[AGENT][NEUTRAL] OK. Well, I can definitely help you with what's needed for your claims. Um, may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] And my phone number is [PII].
[AGENT][NEUTRAL] And Ms. [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] 02459557
[AGENT][NEUTRAL] Can you repeat that for me, please? I'm sorry.
[CUSTOMER][NEUTRAL] Policy number, um, it's right on the explanation of benefits. It says 02459557.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I think I missed the 7.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, here we go, and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Sure, it's 13-1960 uh [PII] and date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So let me see if these two claims are the same. Hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] OK, and this is for claim number 3556199?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] It looks like, let me see if these dates are the same, but it looks like from what was sent in like after it was denied, it looks like it was paid out on, but let me see, this is two different claims. Um, do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] OK, first, what date of service are you looking at? Because there's multiple ones listed here. The one I'm calling about right now specifically is 12-7-2023.
[AGENT][NEUTRAL] And that one's asking for the diagnosis codes with the and the itemized bill.
[CUSTOMER][NEGATIVE] Yes, and when I look at what I they had me send and I faxed to you guys, um, it's there is a code there and a description says office outpatient established so they're telling me they don't have anything else they can give me to help you guys process.
[AGENT][NEUTRAL] Wait a minute.
[AGENT][NEUTRAL] You, you're saying the documents that you sent in with this claim, so I'm just gonna pull it up so I can see. Is that what you're referencing, the documents that you sent in? OK. Hold on one second. Let me pull that up so I can look with you. You're welcome.
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Oh, that's the explanation of benefits.
[AGENT][NEUTRAL] Hold on one moment. I'm trying to locate the documents so I can look with you.
[AGENT][MIXED] But it keeps pulling up the, uh, yeah, but it keeps pulling up the explanation of benefits for the claim. I need the documents sent with the claim, but I believe I just found it. 6.
[CUSTOMER][NEUTRAL] Oh, OK, the one I faxed in?
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So it's 11 pages, hospital indemnity.
[AGENT][NEUTRAL] OK, here goes the billing. Let me see.
[AGENT][NEUTRAL] What kind of code is on there?
[CUSTOMER][NEUTRAL] You found the one with return sleep patient visit?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Oh good. OK.
[AGENT][NEUTRAL] I'm looking at the
[AGENT][NEUTRAL] This looks like the bill. It, it, it loads like page by page. So once I click on the next page, I got to wait for it to load and I got to remember what was on the page before it. OK, here we go. 99214 office visit.
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If you'd like, I can call the, looks like this is Park Nicolet.
[CUSTOMER][NEUTRAL] No, no, this one is M Health Fairview.
[AGENT][NEUTRAL] Wait, say that and Health therapy you said?
[CUSTOMER][NEUTRAL] Yes, sleep centers, yeah.
[AGENT][NEUTRAL] Maybe I need to keep looking down.
[AGENT][NEUTRAL] And this one says TRIA.
[CUSTOMER][NEUTRAL] Oh, that's Trea that's a different provider.
[AGENT][NEUTRAL] Yeah, I only see those two, but either way, is the one that you have, is it a breakdown like these other two bills?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It shows.
[CUSTOMER][NEUTRAL] Um, the charges?
[CUSTOMER][NEUTRAL] And the total balance, which are the same $661 then it says return sleep visit to M Health Fairview Sleep Center Edina with an account number and it for charges, the date is [PII] the service date. The code is 9921501.
[CUSTOMER][NEUTRAL] Um, the provider is listed and then for the description it says office slash outpatient established and then it says high MDM whatever MDM stands for.
[AGENT][NEUTRAL] OK, so if, so this is, so this is the difference. So these bills and the bill that you just explained, these, these are itemized bills, but this is your patient copy of the itemized bill. If you have a phone number for them, I still don't mind. I can. Oh, we have a company meeting.
[AGENT][NEUTRAL] I can give them a call, um, what you, what you're needing is a universal bill. So those codes that you have there, those are codes, but those are procedure codes that tells us the place of service and what treatment was done. The diagnosis codes tells us why it was medically necessary for those things for that treatment. So we can't like pay out on the claim unless we can
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] Um, prove medical necessity. So that's why diagnosis is needed versus these are called procedure codes.
[CUSTOMER][NEUTRAL] You need diagnosis codes versus procedure codes. You need them both actually.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, we really need them both, but yes, we have the procedure codes here. These are just anywhere that you see that DH 0181, that's asking for the diagnosis code so we can prove medical necessity to pay out.
[AGENT][NEUTRAL] Or give the decision. But how you do, how you, um, all you'll need to do is just call to the provider and say you need a, is this a hospital or was this like a doc, oh, it was an office visit, it was a doctor's office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, yep.
[AGENT][NEUTRAL] OK, well then I would um I would just call the doctor's office and let them know you need their version of the itemized bill. Um, they may call it a universal bill, but it's the same document.
[AGENT][NEUTRAL] And it needs to have
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] The diagnosis code?
[AGENT][NEUTRAL] Or ICD 10, like igloo, Charlie, David, and then the number 10 codes.
[CUSTOMER][NEUTRAL] Igloo Charlie David Igloo Charlie David 10.
[AGENT][NEUTRAL] Mhm, ICD 10, that's the abbreviation for the long word for diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the other one.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Procedure codes, it may say CPT like Charlie, Paul, Tango.
[CUSTOMER][POSITIVE] Charlie Paul Tango procedure call. I love your, um, Charlie Paul Tango, that sounds fun. OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right, so, uh, I don't know. I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You want to do this? Um, so we have a company meeting at, we're in Central time, so we have a company meeting at [PII]. Um, if you like, I can like leave myself a note to give you a call after the meeting and we can call them together, so I can ask them for the documents.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Um, oh, you know what, you explained everything very well to me. Um, I, I'll give it a call. You, you've got lots going on. If I have more trouble though, I'm gonna call you guys back and I hope I get you again, OK?
[AGENT][NEUTRAL] OK. Well, yes, I'm the only [PII] here.
[CUSTOMER][NEGATIVE] So don't go anywhere.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All right, thank you for explaining. I'll give him a call and see what I can get.
[AGENT][NEUTRAL] Alrighty. Well, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] I know that should do it. Just introduce me to Charlie Paul so we can tango.
[AGENT][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] I need some fun in my life.
[AGENT][NEUTRAL] Well, I need to be introduced too.
[CUSTOMER][POSITIVE] All right, well, good luck to both of us.
[AGENT][NEUTRAL] You get Charlie, I get Paul, and we can tango.
[CUSTOMER][POSITIVE] That's right. That sounds fun.
[AGENT][POSITIVE] Oh my gosh.
[CUSTOMER][POSITIVE] Well you have a fun company meeting.
[AGENT][POSITIVE] Thank, thank you. Well, I thank you for calling ATL. I hope you have a good day. I'll talk to you soon.
[CUSTOMER][NEUTRAL] OK, talk to you later.
[CUSTOMER][NEUTRAL] OK, you too, [PII]. Bye bye.
[AGENT][NEUTRAL] All right, bye bye.